I need some help coming up with a 3rd Dx for my pt. The 2 I have completed so far were
Risk for decreased cardiac output and Risk for injury. I can't come up with a 3rd for the life of me.
Here is ALL the pt info I have written on my pt research sheet. I wish I had more but I did exactly as my instructor asked which turns out to not be enough.
86 yr old female; Self care
Current dx: nose bleed, rapid atrial fibrillation
PMH: stroke, bilateral cataracts, atrial fibrillation/flutter, hypertenstion, diabetes, hypercholesterolemia, osteoarthritis, lymphedema, breast cancer, colon cancer
PSH: catract sx, colectomy, partial thyroidectomy, carotid endarterectomy, hysterectomy, joint replacement, R. mastectomy, R hand ORIF due to fx
Social hx: lives with family, no illicit drugs, tobacco or alcohol abuse
Labs: RBC (4.51) Hgb (13.3) Hct (40.1) WBC (5.9) Lymphs (39.9) PTT (112.8) PT (11.3) INR (1.0) Glu (131 H) BUN (13) Creat (0.9) eGFR (74) Na (139) K (3.6) Cl (104) CO2 (28) Mg (1.6 L) Ca (9.2) CK-MB (0.6) Troponin I (
Vital Signs 8am: T: 97.6 BP 153/67 Resp: 20 SPO2: 94 on room air Pulse: 70 Pain: 7/10 (L shoulder from old fx)
Vital Signs 11am: T: 97.2 BP 121/56 Resp: 20 SPO2: 97 on room air Pulse: 68 Pain: 7/10 (L shoulder from old fx)
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
So looking at all your information you have available what do YOU see that is important to the patient RIGHT NOW?
Risk for decreased cardiac output and Risk for injury. I can't come up with a 3rd for the life of me.
Here is ALL the pt info I have written on my pt research sheet. I wish I had more but I did exactly as my instructor asked which turns out to not be enough.
86 yr old female; Self care
Current dx:nose bleed, rapid atrial fibrillation
PMH: stroke, bilateral cataracts, atrial fibrillation/flutter, hypertenstion, diabetes, hypercholesterolemia, osteoarthritis, lymphedema, breast cancer, colon cancer
PSH: catract sx, colectomy, partial thyroidectomy, carotid endarterectomy, hysterectomy, joint replacement, R. mastectomy, R hand ORIF due to fx
Social hx: lives with family, no illicit drugs, tobacco or alcohol abuse
Labs: RBC (4.51) Hgb (13.3) Hct (40.1) WBC (5.9) Lymphs (39.9) PTT (112.8) PT (11.3) INR (1.0) Glu (131 H) BUN (13) Creat (0.9) eGFR (74) Na (139) K (3.6) Cl (104) CO2 (28) Mg (1.6 L) Ca (9.2) CK-MB (0.6) Troponin I (
Vital Signs 8am: T: 97.6 BP 153/67 Resp: 20 SPO2: 94 on room air Pulse: 70 Pain: 7/10(L shoulder from old fx)
Vital Signs 11am: T: 97.2 BP 121/56 Resp: 20 SPO2: 97 on room air Pulse: 68 Pain: 7/10(L shoulder from old fx)
She was admitted for Nose Bleed (Epistaxis) She needs to be anti-coagulated because of the A-Fib....(was the patient on any anti-coagulants at home?) therefore she is on a HEPARIN gtt....which puts her at risk for bleeding.
She came in for rapid A-Fib (which she has a history of)which if the arrhythmia re-occurs she would be at risk for decreased cardiac output AND she is on a Cardizem gtt which controls the heart rate however it can also slow the heart too much which also puts her at risk for altered cardiac output. Her A fib make her at an increased chance of a stroke (neurological impairment, circulation to the brain) which she also has a history of stroke.
She has pain. Her pain as reported is 7/10. So her pain is significant. Are you sure her LEFT shoulder pain isn't cardiac? Did you assess for cardiac pain? Just because someone has a history of chronic shoulder pain don't assume that her pain is related to that as she has cardiac issues right now. How would you assess that? Is this your normal pain? Does it hurt more to move or take a deep breath? Does your pain go anywhere else? What makes it better? What makes it worse? Her cardiac enzymes are negative are these recent? Was a 12 lead EKG done? Did you medicate her pain?
Her glucose is elevated. She is on insulin and under stress. Would that put her at risk for unstable glucose?
Can you see the nursing diagnosis in what I have given you?
Esme12, ASN, BSN, RN
20,908 Posts
So looking at all your information you have available what do YOU see that is important to the patient RIGHT NOW?
She was admitted for Nose Bleed (Epistaxis) She needs to be anti-coagulated because of the A-Fib....(was the patient on any anti-coagulants at home?) therefore she is on a HEPARIN gtt....which puts her at risk for bleeding.She came in for rapid A-Fib (which she has a history of)which if the arrhythmia re-occurs she would be at risk for decreased cardiac output AND she is on a Cardizem gtt which controls the heart rate however it can also slow the heart too much which also puts her at risk for altered cardiac output. Her A fib make her at an increased chance of a stroke (neurological impairment, circulation to the brain) which she also has a history of stroke.
She has pain. Her pain as reported is 7/10. So her pain is significant. Are you sure her LEFT shoulder pain isn't cardiac? Did you assess for cardiac pain? Just because someone has a history of chronic shoulder pain don't assume that her pain is related to that as she has cardiac issues right now. How would you assess that? Is this your normal pain? Does it hurt more to move or take a deep breath? Does your pain go anywhere else? What makes it better? What makes it worse? Her cardiac enzymes are negative are these recent? Was a 12 lead EKG done? Did you medicate her pain?
Her glucose is elevated. She is on insulin and under stress. Would that put her at risk for unstable glucose?
Can you see the nursing diagnosis in what I have given you?